Chen Shey-Ying, Wang Jann-Tay, Chen Tony Hsiu-Hsi, Lai Mei-Shu, Chie Wei-Chu, Chien Kuo-Liong, Hsueh Po-Ren, Wang Jiun-Ling, Chang Shan-Chwen
From Department of Emergency Medicine (SYC); Division of Infectious Diseases (JTW, SCC), Department of Internal Medicine; and Department of Laboratory Medicine (PRH), National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei; Institute of Preventive Medicine (SYC, JTW, MSL, WCC, KLC); and Institute of Epidemiology (THHC), College of Public Health, National Taiwan University, Taipei; and Department of Internal Medicine (JLW), E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.
Medicine (Baltimore). 2010 Sep;89(5):285-294. doi: 10.1097/MD.0b013e3181f1851e.
Community-associated methicillin-resistant Staphylococcus aureus (MRSA) has become an important pathogen in community and nosocomial infections. The impact of these emerging MRSA strains on mortality in adult patients with community-onset S aureus bacteremia remains uncertain. We defined community strain MRSA (CoSt-MRSA) and hospital strain MRSA (HoSt-MRSA) according to the results of staphylococcus cassette chromosome mec (SCCmec) molecular typing: CoSt-MRSA isolates had SCCmec type IV or V genes, and HoSt-MRSA isolates had SCCmec type I, II, or III genes. We quantitatively evaluated the impact of the MRSA strain on mortality in patients with CoSt-MRSA or HoSt-MRSA bacteremia by comparison with mortality in patients with methicillin-susceptible S aureus (MSSA) bacteremia.We studied an observational cohort of 500 patients with MSSA bacteremia, 111 patients with CoSt-MRSA, and 133 patients with HoSt-MRSA bacteremia from January 1, 2001, through December 31, 2007. The 90-day cumulative probability of survival in patients with MSSA, CoSt-MRSA, and HoSt-MRSA bacteremia was 71%, 70%, and 55%, respectively (p = 0.014, by Wilcoxon rank-sum test).Compared to patients with MSSA bacteremia, patients with HoSt-MRSA bacteremia were associated with an increased risk of mortality in the first multivariate analysis model adjusting for all potential confounders (hazard ratio [HR], 1.525; 95% confidence interval [CI], 1.091-2.131), in the second model adjusting for all confounders except acute severity of bacteremia (HR, 1.489; 95% CI, 1.071-2.070), and in stratified analysis in patients with low Charlson comorbidity scores (score 0-2) (HR, 3.093; 95% CI, 1.507-6.350).Compared to patients with MSSA bacteremia, patients with CoSt-MRSA bacteremia did not show significant differences in mortality rate in the 2 multivariate analysis models (first model: HR, 1.106; 95% CI, 0.748-1.637; second model: HR, 1.028; 95% CI, 0.697-1.516) or in stratified analysis (HR, 1.092; 95% CI, 0.539-2.214).In conclusion, using MSSA as reference, traditional hospital strain MRSA had a higher impact on bacteremia mortality than community strain MRSA.
社区获得性耐甲氧西林金黄色葡萄球菌（MRSA）已成为社区和医院感染中的一种重要病原体。这些新出现的MRSA菌株对社区起病的金黄色葡萄球菌菌血症成年患者死亡率的影响仍不确定。我们根据葡萄球菌盒式染色体mec（SCCmec）分子分型结果定义了社区菌株MRSA（CoSt-MRSA）和医院菌株MRSA（HoSt-MRSA）：CoSt-MRSA分离株具有IV型或V型SCCmec基因，而HoSt-MRSA分离株具有I型、II型或III型SCCmec基因。通过与甲氧西林敏感金黄色葡萄球菌（MSSA）菌血症患者的死亡率进行比较，我们定量评估了MRSA菌株对CoSt-MRSA或HoSt-MRSA菌血症患者死亡率的影响。
我们研究了一个观察性队列，该队列包括2001年1月1日至2007年12月31日期间的500例MSSA菌血症患者、111例CoSt-MRSA菌血症患者和133例HoSt-MRSA菌血症患者。MSSA、CoSt-MRSA和HoSt-MRSA菌血症患者90天的累积生存概率分别为71%、70%和55%（通过Wilcoxon秩和检验，p = 0.014）。
在第一个针对所有潜在混杂因素进行调整的多变量分析模型中，与MSSA菌血症患者相比，HoSt-MRSA菌血症患者的死亡风险增加（风险比[HR]，1.525；95%置信区间[CI]，1.091 - 2.131）；在第二个针对除菌血症急性严重程度之外的所有混杂因素进行调整的模型中（HR，1.489；95% CI，1.071 - 2.070）；以及在Charlson合并症评分较低（评分0 - 2）的患者分层分析中（HR，3.093；95% CI，1.507 - 6.350）。
与MSSA菌血症患者相比，CoSt-MRSA菌血症患者在两个多变量分析模型中（第一个模型：HR，1.106；95% CI，0.748 - 1.637；第二个模型：HR，1.028；95% CI，0.697 - 1.516）或分层分析中（HR，1.092；95% CI，0.539 - 2.214）的死亡率均未显示出显著差异。
总之，以MSSA为参照，传统医院菌株MRSA对菌血症死亡率的影响高于社区菌株MRSA。
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